"BUSINESS YEAR","STATE CODE","ISSUER ID","SOURCE NAME","VERSION NUMBER","IMPORT DATE","STANDARD COMPONENT ID","PLAN ID","BENEFIT NAME","IS EHB","IS STATE MANDATE","IS COVERED","QUANTITY LIMIT ON SVC","LIMIT QUANTITY","LIMIT UNIT","MINIMUM STAY","EXCLUSIONS","EXPLANATION","EHB VAR REASON","IS SUBJECTED TO DED TIER 1","IS SUBJECTED TO DED TIER 2","IS EXCLUDED FROM INN MOOP","IS EXCLUDED FROM OON MOOP"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0080001","10544CA0080001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0090001","10544CA0090001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0100001","10544CA0100001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0110001","10544CA0110001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0120001","10544CA0120001-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0210001","10544CA0210001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0220001","10544CA0220001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0320004","10544CA0320004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0530001","10544CA0530001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0540001","10544CA0540001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0830001","10544CA0830001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0840001","10544CA0840001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0850001","10544CA0850001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Mental/Behavioral Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0860001","10544CA0860001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0890001","10544CA0890001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0900001","10544CA0900001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Mental/Behavioral Health Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0910001","10544CA0910001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","10544","SERFF","1","2021-03-08 08:38:05","10544CA0920001","10544CA0920001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010001","18126CA0010001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010002","18126CA0010002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010003","18126CA0010003-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010004","18126CA0010004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","18126","SERFF","1","2021-03-08 08:38:05","18126CA0010005","18126CA0010005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150036","27603CA1150036-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150037","27603CA1150037-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150038","27603CA1150038-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150039","27603CA1150039-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1150040","27603CA1150040-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1330004","27603CA1330004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500005","27603CA1500005-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500006","27603CA1500006-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500007","27603CA1500007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500008","27603CA1500008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500009","27603CA1500009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1500010","27603CA1500010-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","27603","SERFF","1","2021-03-08 08:38:05","27603CA1560001","27603CA1560001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","40269","SERFF","1","2021-03-08 08:38:05","40269CA0010014","40269CA0010014-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380001","40513CA0380001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380002","40513CA0380002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380003","40513CA0380003-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380004","40513CA0380004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380005","40513CA0380005-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380006","40513CA0380006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0380013","40513CA0380013-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400001","40513CA0400001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400002","40513CA0400002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400004","40513CA0400004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400005","40513CA0400005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400007","40513CA0400007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400009","40513CA0400009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400020","40513CA0400020-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400021","40513CA0400021-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400022","40513CA0400022-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400023","40513CA0400023-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400024","40513CA0400024-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Mental/Behavioral Health Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400026","40513CA0400026-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Mental/Behavioral Health Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400027","40513CA0400027-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Mental/Behavioral Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400028","40513CA0400028-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400029","40513CA0400029-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Chiropractic Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400030","40513CA0400030-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400031","40513CA0400031-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Mental/Behavioral Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400032","40513CA0400032-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400033","40513CA0400033-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400034","40513CA0400034-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400035","40513CA0400035-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400036","40513CA0400036-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400037","40513CA0400037-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Infertility Treatment",,,"Covered","Yes","1","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400038","40513CA0400038-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Infertility Treatment",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400039","40513CA0400039-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Private-Duty Nursing",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Routine Eye Exam (Adult)",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional facility fee.",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Cosmetic Surgery",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Chiropractic Care",,,"Covered","Yes","20","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Not EHB",,,"Yes","Yes"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Hearing Aids",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Exam(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Item(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Dental Check-Up for Children","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Basic Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Orthodontia - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Major Dental Care - Child","Yes",,"Not Covered",,,,,,,"Dental Only Plan Available",,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Other Law/Regulation",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Nutritional Counseling",,,"Not Covered",,,,,,,,,,,
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Mental/Behavioral Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","40513","SERFF","1","2021-03-08 08:38:05","40513CA0400040","40513CA0400040-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0180001","47579CA0180001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0200001","47579CA0200001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0220001","47579CA0220001-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0240001","47579CA0240001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0270001","47579CA0270001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0290001","47579CA0290001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0310001","47579CA0310001-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0330001","47579CA0330001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0520001","47579CA0520001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0540001","47579CA0540001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0630001","47579CA0630001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47579","SERFF","1","2021-03-08 08:38:05","47579CA0640001","47579CA0640001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","47911","SERFF","1","2021-03-08 08:38:05","47911CA0210001","47911CA0210001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0010004","62683CA0010004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020002","62683CA0020002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0020004","62683CA0020004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0030004","62683CA0030004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040002","62683CA0040002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","62683","SERFF","1","2021-03-08 08:38:05","62683CA0040004","62683CA0040004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520004","67138CA0520004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520005","67138CA0520005-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520006","67138CA0520006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520007","67138CA0520007-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520008","67138CA0520008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520009","67138CA0520009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520010","67138CA0520010-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520011","67138CA0520011-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520012","67138CA0520012-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520013","67138CA0520013-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520014","67138CA0520014-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520015","67138CA0520015-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520016","67138CA0520016-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520017","67138CA0520017-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520018","67138CA0520018-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520019","67138CA0520019-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520020","67138CA0520020-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0520021","67138CA0520021-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630001","67138CA0630001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","67138","SERFF","1","2021-03-08 08:38:05","67138CA0630002","67138CA0630002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080002","67819CA0080002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080003","67819CA0080003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080004","67819CA0080004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080005","67819CA0080005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080006","67819CA0080006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080007","67819CA0080007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080008","67819CA0080008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080009","67819CA0080009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080010","67819CA0080010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080011","67819CA0080011-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080014","67819CA0080014-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080015","67819CA0080015-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080016","67819CA0080016-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080017","67819CA0080017-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080018","67819CA0080018-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0080019","67819CA0080019-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090001","67819CA0090001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090002","67819CA0090002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090003","67819CA0090003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090004","67819CA0090004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090005","67819CA0090005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090006","67819CA0090006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090007","67819CA0090007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090008","67819CA0090008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090009","67819CA0090009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090010","67819CA0090010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090011","67819CA0090011-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090012","67819CA0090012-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090013","67819CA0090013-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090014","67819CA0090014-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090015","67819CA0090015-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090016","67819CA0090016-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090017","67819CA0090017-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090018","67819CA0090018-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Orthodontia - Adult",,,"Not Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,,
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"Yes","Yes"
"2021","CA","67819","SERFF","1","2021-03-08 08:38:05","67819CA0090019","67819CA0090019-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1250001","70285CA1250001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1270001","70285CA1270001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1290001","70285CA1290001-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1310001","70285CA1310001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1320001","70285CA1320001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA1350001","70285CA1350001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040001","70285CA8040001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040002","70285CA8040002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040003","70285CA8040003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040004","70285CA8040004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040005","70285CA8040005-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040006","70285CA8040006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040007","70285CA8040007-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040008","70285CA8040008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040009","70285CA8040009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040010","70285CA8040010-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040011","70285CA8040011-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040012","70285CA8040012-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040014","70285CA8040014-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040015","70285CA8040015-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040016","70285CA8040016-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040017","70285CA8040017-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040018","70285CA8040018-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8040019","70285CA8040019-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050001","70285CA8050001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050002","70285CA8050002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050003","70285CA8050003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050004","70285CA8050004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050005","70285CA8050005-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050006","70285CA8050006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050007","70285CA8050007-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050008","70285CA8050008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050009","70285CA8050009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050010","70285CA8050010-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050011","70285CA8050011-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050012","70285CA8050012-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050014","70285CA8050014-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050015","70285CA8050015-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050016","70285CA8050016-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050017","70285CA8050017-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050018","70285CA8050018-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8050019","70285CA8050019-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060001","70285CA8060001-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060002","70285CA8060002-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060003","70285CA8060003-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060004","70285CA8060004-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060005","70285CA8060005-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060006","70285CA8060006-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060007","70285CA8060007-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060008","70285CA8060008-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060009","70285CA8060009-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060010","70285CA8060010-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060011","70285CA8060011-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060012","70285CA8060012-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060014","70285CA8060014-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060015","70285CA8060015-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060016","70285CA8060016-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060017","70285CA8060017-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060018","70285CA8060018-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8060019","70285CA8060019-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120052","70285CA8120052-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120053","70285CA8120053-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120054","70285CA8120054-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120055","70285CA8120055-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120056","70285CA8120056-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120057","70285CA8120057-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120058","70285CA8120058-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120059","70285CA8120059-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120060","70285CA8120060-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120061","70285CA8120061-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120062","70285CA8120062-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120063","70285CA8120063-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120064","70285CA8120064-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120065","70285CA8120065-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120066","70285CA8120066-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120067","70285CA8120067-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120068","70285CA8120068-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8120069","70285CA8120069-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8130051","70285CA8130051-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150001","70285CA8150001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150002","70285CA8150002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150003","70285CA8150003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150004","70285CA8150004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150005","70285CA8150005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150006","70285CA8150006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150007","70285CA8150007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8150008","70285CA8150008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230001","70285CA8230001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230002","70285CA8230002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230003","70285CA8230003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230004","70285CA8230004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230005","70285CA8230005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230006","70285CA8230006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230007","70285CA8230007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230008","70285CA8230008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230009","70285CA8230009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230010","70285CA8230010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230011","70285CA8230011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230012","70285CA8230012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230013","70285CA8230013-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230014","70285CA8230014-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230015","70285CA8230015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230016","70285CA8230016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230017","70285CA8230017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230018","70285CA8230018-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230019","70285CA8230019-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230020","70285CA8230020-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230021","70285CA8230021-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230022","70285CA8230022-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230023","70285CA8230023-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230024","70285CA8230024-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230025","70285CA8230025-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230026","70285CA8230026-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230027","70285CA8230027-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230028","70285CA8230028-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230029","70285CA8230029-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230030","70285CA8230030-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230031","70285CA8230031-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230032","70285CA8230032-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230033","70285CA8230033-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230034","70285CA8230034-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230035","70285CA8230035-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230036","70285CA8230036-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230037","70285CA8230037-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230038","70285CA8230038-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230039","70285CA8230039-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230040","70285CA8230040-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230041","70285CA8230041-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230042","70285CA8230042-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230043","70285CA8230043-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230044","70285CA8230044-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230045","70285CA8230045-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230046","70285CA8230046-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230047","70285CA8230047-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230048","70285CA8230048-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230049","70285CA8230049-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230050","70285CA8230050-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230051","70285CA8230051-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230052","70285CA8230052-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230053","70285CA8230053-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230054","70285CA8230054-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230055","70285CA8230055-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230056","70285CA8230056-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230057","70285CA8230057-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230058","70285CA8230058-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230059","70285CA8230059-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230060","70285CA8230060-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230061","70285CA8230061-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230062","70285CA8230062-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230063","70285CA8230063-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230064","70285CA8230064-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230065","70285CA8230065-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230066","70285CA8230066-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230067","70285CA8230067-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230068","70285CA8230068-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230069","70285CA8230069-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230070","70285CA8230070-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230071","70285CA8230071-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230072","70285CA8230072-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230073","70285CA8230073-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230074","70285CA8230074-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230075","70285CA8230075-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230076","70285CA8230076-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230077","70285CA8230077-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230078","70285CA8230078-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230079","70285CA8230079-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230080","70285CA8230080-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230081","70285CA8230081-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230082","70285CA8230082-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230083","70285CA8230083-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230084","70285CA8230084-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230085","70285CA8230085-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230086","70285CA8230086-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230087","70285CA8230087-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230088","70285CA8230088-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230089","70285CA8230089-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230090","70285CA8230090-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230091","70285CA8230091-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230092","70285CA8230092-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230093","70285CA8230093-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230094","70285CA8230094-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230095","70285CA8230095-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230096","70285CA8230096-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230097","70285CA8230097-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230098","70285CA8230098-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230099","70285CA8230099-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230100","70285CA8230100-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230101","70285CA8230101-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230102","70285CA8230102-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230103","70285CA8230103-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230104","70285CA8230104-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Infertility Treatment",,,"Covered","Yes","6","Treatment(s) per Lifetime",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230105","70285CA8230105-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230106","70285CA8230106-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230107","70285CA8230107-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","70285","SERFF","1","2021-03-08 08:38:05","70285CA8230108","70285CA8230108-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010001","84014CA0010001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010002","84014CA0010002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010003","84014CA0010003-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010004","84014CA0010004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84014","SERFF","1","2021-03-08 08:38:05","84014CA0010005","84014CA0010005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0040001","84138CA0040001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","84138","SERFF","1","2021-03-08 08:38:05","84138CA0050001","84138CA0050001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010001","92499CA0010001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010002","92499CA0010002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010003","92499CA0010003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010004","92499CA0010004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010005","92499CA0010005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010006","92499CA0010006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010007","92499CA0010007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010008","92499CA0010008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010009","92499CA0010009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010110","92499CA0010110-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010111","92499CA0010111-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010112","92499CA0010112-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010113","92499CA0010113-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010114","92499CA0010114-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010115","92499CA0010115-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010116","92499CA0010116-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010117","92499CA0010117-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Infertility Treatment",,,"Covered","Yes","3","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0010118","92499CA0010118-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020001","92499CA0020001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020002","92499CA0020002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020003","92499CA0020003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020004","92499CA0020004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020005","92499CA0020005-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020006","92499CA0020006-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020008","92499CA0020008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020009","92499CA0020009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Routine Dental Services (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Infertility Treatment",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Long-Term/Custodial Nursing Home Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Private-Duty Nursing",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Routine Eye Exam (Adult)",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This Includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Cosmetic Surgery",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Chiropractic Care",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Hearing Aids",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Basic Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Orthodontia - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Major Dental Care - Adult",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Accidental Dental",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Nutritional Counseling",,,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92499","SERFF","1","2021-03-08 08:38:05","92499CA0020010","92499CA0020010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010004","92815CA0010004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010005","92815CA0010005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010006","92815CA0010006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010007","92815CA0010007-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-01","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-02","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-03","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-04","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Cosmetic Surgery",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-05","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Chiropractic Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Hearing Aids",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Basic Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Orthodontia - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Major Dental Care - Adult",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Accidental Dental",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Nutritional Counseling",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Routine Dental Services (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Infertility Treatment",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Private-Duty Nursing",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","92815","SERFF","1","2021-03-08 08:38:05","92815CA0010008","92815CA0010008-06","Routine Eye Exam (Adult)",,,,,,,,,,"Not EHB",,,"Yes","Yes"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110001","93689CA0110001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0110002","93689CA0110002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120001","93689CA0120001-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120004","93689CA0120004-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0120005","93689CA0120005-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0130002","93689CA0130002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150001","93689CA0150001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0150002","93689CA0150002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160001","93689CA0160001-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160002","93689CA0160002-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0160003","93689CA0160003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","93689","SERFF","1","2021-03-08 08:38:05","93689CA0170001","93689CA0170001-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0010002","97389CA0010002-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0030001","97389CA0030001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Routine Dental Services (Adult)",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Basic Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Orthodontia - Adult",,,"Not Covered",,,,,,,,,,,
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Major Dental Care - Adult",,,"Covered",,,,,,"Please see plan's Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"Yes","Yes"
"2021","CA","97389","SERFF","1","2021-03-08 08:38:05","97389CA0040001","97389CA0040001-01","Accidental Dental",,,"Not Covered",,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300001","99110CA0300001-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300002","99110CA0300002-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300003","99110CA0300003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300004","99110CA0300004-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300009","99110CA0300009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300010","99110CA0300010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300011","99110CA0300011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300012","99110CA0300012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300015","99110CA0300015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300017","99110CA0300017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300039","99110CA0300039-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300041","99110CA0300041-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300042","99110CA0300042-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300043","99110CA0300043-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300045","99110CA0300045-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300046","99110CA0300046-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300049","99110CA0300049-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0300050","99110CA0300050-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340006","99110CA0340006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340007","99110CA0340007-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340008","99110CA0340008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340009","99110CA0340009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340010","99110CA0340010-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340011","99110CA0340011-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340012","99110CA0340012-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340013","99110CA0340013-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340014","99110CA0340014-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340015","99110CA0340015-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340016","99110CA0340016-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340017","99110CA0340017-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340018","99110CA0340018-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340019","99110CA0340019-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340020","99110CA0340020-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340021","99110CA0340021-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340022","99110CA0340022-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340023","99110CA0340023-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340024","99110CA0340024-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340025","99110CA0340025-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340026","99110CA0340026-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340027","99110CA0340027-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340028","99110CA0340028-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340029","99110CA0340029-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340030","99110CA0340030-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340031","99110CA0340031-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340032","99110CA0340032-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340033","99110CA0340033-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340034","99110CA0340034-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0340035","99110CA0340035-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400003","99110CA0400003-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400006","99110CA0400006-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400007","99110CA0400007-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400008","99110CA0400008-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400009","99110CA0400009-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400010","99110CA0400010-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400013","99110CA0400013-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400016","99110CA0400016-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400017","99110CA0400017-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400018","99110CA0400018-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400019","99110CA0400019-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400020","99110CA0400020-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400023","99110CA0400023-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400026","99110CA0400026-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400027","99110CA0400027-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400028","99110CA0400028-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400029","99110CA0400029-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-04","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-05","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400030","99110CA0400030-06","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400033","99110CA0400033-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400036","99110CA0400036-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400037","99110CA0400037-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400038","99110CA0400038-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400039","99110CA0400039-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Specialist Visit","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400040","99110CA0400040-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400043","99110CA0400043-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400046","99110CA0400046-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400047","99110CA0400047-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400048","99110CA0400048-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400049","99110CA0400049-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"The medical deductible does not apply to your first three visits combined for primary care, urgent care, mental health, and substance use disorder treatment office visits.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400050","99110CA0400050-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400069","99110CA0400069-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400070","99110CA0400070-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400071","99110CA0400071-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400072","99110CA0400072-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400073","99110CA0400073-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-02","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Specialist Visit","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder facility fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"This includes labor and delivery, mental health, and substance use disorder professional fee.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Skilled Nursing Facility","Yes",,"Covered","Yes","100","Days per Benefit Period",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Chiropractic Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Weight Loss Programs","Yes",,"Not Covered",,,,,,,"Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Routine Eye Exam for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Eye Glasses for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Dental Check-Up for Children","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0400074","99110CA0400074-03","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410009","99110CA0410009-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410010","99110CA0410010-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410011","99110CA0410011-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410012","99110CA0410012-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410013","99110CA0410013-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410014","99110CA0410014-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410015","99110CA0410015-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410016","99110CA0410016-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410051","99110CA0410051-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410052","99110CA0410052-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410053","99110CA0410053-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410054","99110CA0410054-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410057","99110CA0410057-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Infertility Treatment",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410061","99110CA0410061-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410065","99110CA0410065-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Primary Care Visit to Treat an Injury or Illness","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Specialist Visit","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes",,"Covered",,,,,,,,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Outpatient Surgery Physician/Surgical Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Hospice Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Routine Dental Services (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Infertility Treatment",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"Yes","Yes"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Long-Term/Custodial Nursing Home Care",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Private-Duty Nursing",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Routine Eye Exam (Adult)",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Urgent Care Centers or Facilities","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Home Health Care Services","Yes",,"Covered","Yes","100","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Emergency Room Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Emergency Transportation/Ambulance","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Inpatient Hospital Services (e.g., Hospital Stay)","Yes",,"Covered",,,,,,"Including labor and delivery, mental health, and substance use disorder facility fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Inpatient Physician and Surgical Services","Yes",,"Covered",,,,,,"Includes labor and delivery, mental health, and substance use disorder professional fee?",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Bariatric Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Cosmetic Surgery",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Skilled Nursing Facility","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Prenatal and Postnatal Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Delivery and All Inpatient Services for Maternity Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Mental/Behavioral Health Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Mental/Behavioral Health Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Substance Abuse Disorder Outpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Substance Abuse Disorder Inpatient Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Generic Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Non-Preferred Brand Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Specialty Drugs","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Outpatient Rehabilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Habilitation Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Chiropractic Care",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Durable Medical Equipment","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Hearing Aids",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Imaging (CT/PET Scans, MRIs)","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Preventive Care/Screening/Immunization","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Routine Foot Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Acupuncture","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Weight Loss Programs","Yes",,"Not Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Not EHB",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Routine Eye Exam for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Eye Glasses for Children","Yes",,"Covered","Yes","1","Visit(s) per Year",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Dental Check-Up for Children","Yes",,"Covered","Yes","1","Visit(s) per 6 Months",,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Substantially Equal",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Rehabilitative Speech Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Well Baby Visits and Care","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Laboratory Outpatient and Professional Services","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","X-rays and Diagnostic Imaging","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Basic Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Orthodontia - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Major Dental Care - Child","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Basic Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Orthodontia - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Major Dental Care - Adult",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Abortion for Which Public Funding is Prohibited",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Other Law/Regulation",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Transplant","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Accidental Dental",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Dialysis","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Allergy Testing","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Chemotherapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Radiation","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Diabetes Education","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Prosthetic Devices","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Infusion Therapy","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Treatment for Temporomandibular Joint Disorders","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Nutritional Counseling",,,,,,,,,,,,,,
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Reconstructive Surgery","Yes",,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.",,,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Outpatient Services Office Visit",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Mental/Behavioral Health Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Delivery and all Inpatient Services Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Substance Use Disorder Inpatient Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
"2021","CA","99110","SERFF","1","2021-03-08 08:38:05","99110CA0410069","99110CA0410069-01","Emergency Room Professional Fee",,,"Covered",,,,,,"Please see plan?s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.","Additional EHB Benefit",,,"No","No"
